NURSING DIAGNOSES OF A

CLIENT WITH CHD

1
A 65- year-old retired solicitor, is admitted to CCU due to
suddenly severe chest discomfort and falling on the floor
during playing squash. He presents with SOB, weak pulse
and in semi-conscious. ECG shows lateral MI with ST
segment changes.
2
Nursing Diagnoses
1.Acute Pain
2.Ineffective cardiac tissue perfusion
3.Decreased cardiac output
4.Activity intolerance
5.Ineffective therapeutic regime management

3
ACUTE PAIN
Related to
1. reduced coronary blood flow to myocardium (decrease oxygen supply🡩
anaerobic metabolism🡩 lactic acid release🡩 irritants to nerves in myocardium
🡩pain)
2. pericarditis
As evidenced by
1. verbalisation of pain (pain score)
2. non-verbal signs of pain: grimacing, rubbing neck, jaw or arm, cold sweating,
pallor, change in vital signs

GOALS: Client will verbalise relief of chest pain

4
ACUTE PAIN
NURSING INTERVENTIONS
1. Assess for verbal and nonverbal signs of
pain regularly. Verify nonverbal indicators of
pain with the client.
2. Document history, characteristics and the
intensity of the pain using a standard pain
scale, e.g. NRS
3. Administer oxygen as prescribed and
measure oxygen saturation.
4. Administer aspirin as ordered.
5. Administer SL/PO/IV nitroglycerin as
ordered to relieve chest pain, maintaining SBP and peripheral vessels, reducing cardiac work, including
≥ 100mmHg.
RATIONALE
Pain assessment allows early intervention to reduce the
risk of further damage.
Pain scales provide an objective tool for measuring pain
and assessing pain relief or reduction.
Supplemental oxygen increases oxygen supply to the
myocardium, decreasing ischemia and pain.
Aspirin decreases platelet aggregation and significantly
improves mortality and morbidity rates when used within
24 hours of onset of chest pain.
Nitroglycerin decreases chest pain by dilating coronary
collateral channels, thus improving blood flow to
ischaemic tissue.
5
 ACUTE PAIN
NURSING INTERVENTIONS
6. Administer morphine sulfate
intravenously as ordered.
7. Administer medications, e.g.
beta-blockers, calcium channel blockers,
ACEI /ARBs, statins and thrombolytic
agents as prescribed.
9. Promote physical and psychological rest
with the provision of information and
emotional support.
RATIONALE
Morphine sulfate as an opioid analgesic can reduce
the cardiac workload through vasodilation, reduce
client anxiety.
These agents can improve the myocardial
oxygenation, prevent infarction recurrence.
Rest decrease cardiac workload and sympathetic
nervous system stimulation, promoting comfort.
Information and emotional support help decrease
anxiety and provide psychologic rest.
6
INEFFECTIVE TISSUE PERFUSION
• Related to reduce coronary blood flow

• As evidenced by increased cardiac injury biomarkers (troponin I and

troponin T, CK-MB, myoglobin) / changes of ST-segment in ECG

• GOALS: Client will exhibit adequate cardiac perfusion e.g. free of

chest pain related to angina and free from arrhythmias.

7
 INEFFECTIVE TISSUE PERFUSION
NURSING INTERVENTIONS
1. Assess and document vital signs. Report if any
abnormality is detected e.g. tachyarrhythmia,
drop in BP, unrelieved chest pain.
2. Assess for changes in level of consciousness
(LOC); any 🡩urine output; moist, cool, pale,
mottled, or cyanotic skin; dusky or cyanotic
mucous membranes and nail beds;
diminished/absent peripheral pulse; and delayed
capillary refill.
3. Auscultate heart and breath sounds to note
abnormal heart sounds/murmur or adventitious
lung sounds.
4. Monitor ECG rhythm continuously and obtain a
12-lead ECG to assess complaints of chest pain.
RATIONALE
Decreased cardiac output activates
compensatory mechanisms that may cause
tachycardia and vasoconstriction, increasing
cardiac workload.
These are manifestations of impaired tissue
perfusion with systemic vasoconstriction resulting
from diminished cardiac output .
Abnormal heart or adventitious lung sounds may
indicate impaired cardiac filling or output,
increasing the risk for decreased tissue perfusion.
Dysrhythmias can further impair cardiac output
and tissue perfusion.
8
 INEFFECTIVE TISSUE PERFUSION
NURSING INTERVENTIONS
5. Monitor oxygen saturation levels. Administer
oxygen as ordered to reduce myocardial hypoxia.
Obtain and assess ABG as indicated.
6. Administer anti-anginal and antiarrhythmic
medications as needed.
7. Obtain serial cardiac injury markers, e.g.
troponin I, troponin T, CK-MB to monitor the extent
of myocardial damage.
8. Plan for invasive haemodynamic monitoring. to
facilitate management and treatment evaluation.
RATIONALE
Oxygen saturation is an indicator of gaseous
exchange, tissue perfusion and the effectiveness
of oxygen administration. ABGs provide a more
precise measurement of blood oxygen levels and
allow assessment of acid-base balance.
These medications maintain myocardial perfusion
and reduce cardiac work.
Level of cardiac markers, isoenzymes in particular,
correlate with the extent of myocardial damage.
Invasive haemodynamic monitoring facilitates
management and treatment evaluation.
9
 DECREASED CARDIAC OUTPUT
Related to related to loss of myocardial contractility associated with myocardial damage

As evidenced by
1. hyper/ hypotension,
2. irregular pulse (tachycardia >100 bpm; bradycardia <60 bpm)
3. diminished/absent peripheral pulse
4. irregular respiration
5. confusion, syncope, dizziness
6. moist, cool, mottled, pale or cyanotic skin, oliguria (U/O <30 ml/hr)

GOALS: Client will maintain optimum cardiac output, as evidenced by normal heart
rate, clear lung sound, urine output > 30ml/hr, pinkish , warm and dry skin

10
 DECREASED CARDIAC OUTPUT
NURSING INTERVENTIONS RATIONALE
1. Monitor and report for S/S of decreased cardiac output: Decreased cardiac output
• 🡩, 🡩 and/or irregular heart rate activates compensatory
• 🡩 respiratory rate mechanisms that may cause
• 🡩/ 🡩 blood pressure tachycardia, vasoconstriction,
• Abnormal heart and lung sound venous congestion, increasing
• 🡩 urine output cardiac workload and
hypoperfusion to the kidneys
and brain.
2. Monitor and report for S/S of MI:
• Sudden, severe and persistent chest pain
• Loss of consciousness
• Dyspnea
• Fever
• Elevated cardiac biomarkers (Troponin I, Troponin T, CK-MB)
• ECG changes: ST segment elevation or depression, T wave
inversion and/or presence of Q wave
11
 DECREASED CARDIAC
NURSING INTERVENTIONS
OUTPUT RATIONALE
3. Initiate appropriate protocols or standing orders, Nursing management differs based on etiology,
depending on the underlying etiology of the e.g. measures to help increase preload for
problem affecting ventricular function. hypovolemia.

4. Position the client with lower limbs elevated, This position can help increase preload and
unless ventricular function is impaired. enhance cardiac output.

5. During acute episodes, maintain absolute bed This measures decrease metabolic demand.
rest and minimise all controllable stressors.
Administer IV morphine PRN according to
protocol. Use with caution if client is hypotensive.

6. Assist client with measures to conserve Adequate rest reduces oxygen consumption and
strength, such as resting before and after activities decreases the risk of hypoxia.
(e.g. light meal, bed bath).
12
 DECREASED CARDIAC OUTPUT
NURSING INTERVENTIONS RATIONALE
7. Monitor intake and output as well as weight. Changes can indicate fluid retention.

8. Administer IV fluids cautiously in a client with A client with poorly functioning ventricles may not
impaired ventricular function. tolerate increased blood volumes.

9. Administer inotropic and vasoactive agents (e.g. Medications improve contractility.

digoxin, dopamine, dobutamine) as prescribed.

10. Assist with insertion and/or maintenances of Advanced technology improves cardiac function
mechanical cardiac assist devices as indicated and decrease cardiac workload and oxygen
(e.g. intra-aortic balloon pump, coronary demand.
angiography +/- PCI).

13
ACTIVITY INTOLERANCE
Related to imbalance between oxygen supply and demand and fatigue

As evidenced by excessively increase/ decrease of heart rate, respiration rate

and/or dyspnea after certain activity

GOALS: Client will tolerate progressive activity

14
 ACTIVITY INTOLERANCE
NURSING INTERVENTIONS RATIONALE
1. Assess client’s respiratory and cardiac status Response to activity can be evaluated by
before activity. comparing pre-activity blood pressure, pulse and
respiratory rate with post-activity results. These, in
turn, are compared with recovery time.
2. Observe and document response to activity. These are evidences of compromised cardiac or
Discontinue the activity if the client with signs of respiratory ability.
abnormal response includes:
• 🡩 pulse rate
• 🡩 systolic pressure
• 🡩 diastolic pressure by 15 mmHg
• 🡩arrhythmia
• ECG changes: ST segment
depression/elevation
• Chest pain, dizziness, dyspnea
• Skin colour changes
• Excessive fatigue

15
 ACTIVITY INTOLERANCE
NURSING INTERVENTIONS RATIONALE
3. Increase the activity gradually. Adjusting frequency, duration and intensity of
activity until the desired level is achieved.
4. Encourage adequate rest periods especially Rest relieves the symptoms of activity intolerance
before activities. and reduces excess energy expenditure.

5. Instruct client not to hold breath while exercising Avoid activities that create a Valsalva response.
or moving and not to strain for bowel open.
6. Maintain progression of activity as ordered by Strategies that are individualised can increase
physician or cardiac rehabilitation team. motivation.

7. Provide emotional support when increasing Promote participation in activities to achieve a

activity. Encourage client for self care when level of activity desired by the client for the
condition is stable. therapeutic regimen.

8. Take prophylactic TNG prior to engage in Take TNG to treat or prevent attacks of chest pain
activities. during activity.
16
INEFFECTIVE
HEALTH MAINTENANCE
Related to lack of knowledge of risk factors, disease
process, rehabilitation activities and medication

As evidenced by
1. unable to verbalise causative and preventive factors
2. maintenance of dysfunctional destructive habits
3. multiple questions from client/significant others

GOALS: Client/significant others will be able to identify

and manage modifiable risk factors.
17
 INEFFECTIVE
HEALTH MAINTENANCE
NURSING INTERVENTIONS
1. Discuss risk factors for CHD, stressing that
changing or managing those factors that can be
modified reduces the client’s overall risk for the
disease.
2. Discuss the immediate benefits of smoking
cessation. Provide resources materials from
Hospital Authority or Department of Health. Refer
to a structured smoking cessation programme to
increase the likelihood of success in quitting.
3. Help the client identify specific sources of
psychosocial and physical support for smoking
cessation, dietary and lifestyle changes.
RATIONALE
Clients with significant non-modifiable risk factors
may be discouraged, reducing their ability to
eliminate or control modifiable risk factors.
Long-time smokers may assume that the damage
from smoking has already been done, and quitting
would not be worth for the effort.
Support persons, groups and aids such as
nicotine patches help the client achieve success
and provide encouragement during difficult times.
18
 INEFFECTIVE
HEALTH MAINTENANCE
NURSING INTERVENTIONS RATIONALE
4. Discuss the benefits of regular exercise for Engaging in preferred activities with a partner
cardiovascular health and weight loss. Encourage maintains motivation and increase the likelihood of
planning for 30 minutes of continuous and maintaining an exercise programme.
favourite aerobic activity most days of the week
with a partner.
5. Provide information and teaching about Teaching is important to promote understanding of
prescribed medications such as and compliance with the prescribed medication
cholesterol-lowering medications. Discuss the regimen.
relationship between hypertension, diabetes,
hyperlipidaemia and CHD. Participate in cardiac
rehabilitation programme.

19